Basic Information
| Provider Information | |||||||||
| NPI: | 1205910320 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GAINESVILLE PHYSICAL THERAPY & WELLNESS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4113 NW 6TH ST STE C | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326090731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523766300 | ||||||||
| FaxNumber: | 3523720661 | ||||||||
| Practice Location | |||||||||
| Address1: | 4113 NW 6TH ST STE C | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326090731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523766300 | ||||||||
| FaxNumber: | 3523720661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 03/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | LOWER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3523766300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT12687 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | Y912S | 01 | FL | BCBS | OTHER | DH0372 | 01 | FL | RAILROAD MEDICARE | OTHER |